Child Abuse, Neglect and Trauma: attachment, development and interventions

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1 Child Abuse, Neglect and Trauma: attachment, development and interventions Action for Children Preparing for the Future York, 9 February 2010 David Howe University of East Anglia Norwich

2 Brain Genes Environment G X E Nature via nurture Genes are designed to work in an environment

3 cortex limbic system brain stem cerebellum

4 Bruce Perry: The ChildTrauma Academy, 5161 San Felipe, Suite 320 Houston, Texas 77056

5 Neurosequential development: From the bottom up, and the inside out. The foundational principle of brain development is that neural systems organize and become functional in a sequential manner. (Perry 2006)

6 Neurosequential development: Children who are regulated gradually learn to regulate themselves physiologically, emotionally, cognitively. They can think about and reflect on feeling. They become less reactive, less impulsive, more reflective, more thoughtful.

7 Neurosequential development: The development of each system to some extent depends on the coherent and satisfactory development of earlier systems. If earlier experiences compromise a systems neurological development, even if later experiences are appropriate, the more mature system can t necessarily take advantage of it. The key to healthy development is getting the right experience at the right time (Perry 2006)

8 Neurosequential development: Neglect = lack of sensory experience during sensitive periods of brain development; the absence of critical organising experiences at key times during development. Although critical, neglect is hard to see. Abuse = extreme sensory experiences during sensitive periods of brain development (eg hyperarousal, trauma) (Perry 2002)

9 Brain development and the early caregiving environment The brain is a self-organising developmental system. Allan Schore Brains feed on experience particularly social and emotional experience (nb deprived versus enriched environments). An individual s brain develops capabilities suited for the environment in which he or she is raised. The self-organisation of the developing brain takes place in the context of a relationship with other selves.

10 John Bowlby

11 SURVIVAL DEVELOPMENT OF MIND AND PSYCHOLOGICAL SELF Attachment system Intersubjectivity

12 Mary Ainsworth

13 How attachment influences adaptation First, the attachment system serves a major protective and coping function when the individual is faced with danger ( safe haven function of the attachment relationship). Second, confidence in the caregiver s availability is thought to enhance the child s ability to explore in novel and challenging situations ( secure base function)

14 Affect regulation How young minds form in the context of close relationships (Allan Schore)

15 ATTACHMENT None of us in born with the capacity to regulate our own emotions. The caregiver- child regulatory system evolves where the infant s signals of changes in state are understood and responded to by the caregiver, thereby becoming more regulated. Peter Fonagy 2000

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17 Sensitivity and mentalisation The child has the opportunity to find himself/herself in the other as someone with thoughts and feelings - with a mind. The child recognises themselves as an intentional being. Peter Fonagy The parents capacity to observe the child s mind seems to facilitate the child s general understanding of minds, and hence his/her self-organisation through the medium of a secure attachment.

18 Social cognition Social understanding

19 Bateman and Fonagy 2004 Birth of the Psychological Self Attachment figure discovers infant s mind (subjectivity) Internalization Representation of infant s mental state Core of psychological self Attachment figure Infant Inference Child Infant internalizes caregiver s representation to form psychological self

20 Optimal development Secure Resilient (mentalisation, high self esteem, self efficacy) Emotionally intelligent (high social cognition, social understanding, empathy) Complex, integrated brain Coherent and organised states of mind

21 Patterns of attachment INSECURE organised SECURE ~60% INSECURE organised AVOIDANT ~20% AMBIVALENT ~12% INSECURE DISORGANISED

22 Helpless/hostile caregiving The helpless stance involves failing to provide reassurance and protection to the child Helpless states of mind - without strategies - a state in which the parent abdicates care and protection for the child, failing to terminate the child s attachment system

23 Helpless/hostile caregiving Feelings of fear, helplessness and hostility which result in frightening/ frightened behaviour might be the result of parents being unable to control frightening memories or emotions associated with their own childhood loss/traumas.

24 Helpless/hostile caregiving Helpless states of mind - infant s pain and fear evokes carer s own past unresolved losses and fears + helplessness to know how to find comfort and safety. Carers find it difficult to hear, respond to and help modulate fear and distress in their child. Carers therefore both evoke fear in their children AND fail to recognise it.

25 Helpless/hostile caregiving If the parent must restrict her conscious attention to the infant s fear-related cues in order not to evoke her own unresolved fearful experiences, the parent s fluid responsiveness to the infant s attachment-related communications become restricted. The more pervasive these restrictions on the parent s conscious attention and responsiveness, the more the parent s need to regulate her own negative arousal will take precedence over the infant s concomitant need for a soothing response to his/her attachmentrelated communications.

26 Disorganised/disorientated attachments: infancy Disorganised attachments arise when the attached infant has been alarmed by the parent rather than the external situation. The parent is experienced as: Frightening physically alarming/hostile dangerous parental behaviour Frightened psychologically alarming parental behaviour/helpless

27 Simultaneous activation of two incompatible behavioural responses: FEAR and ATTACHMENT (avoidance) (approach)

28 Fear and disorganisation Normally, the attachment figure is the developing child s primary solution to fear. However, when the carer is the source of fear, attachment behaviour (approach) and fear (escape/ avoidance) are incompatible, leading to conflict. fear without escape; fright without solution. Child remains fearfully aroused, overwhelmed and behaviourally disorganised lack of mental integration; unintegrated state of mind. Hesse and Main

29 Relational trauma

30 Caregiving and disorganised attachments Physical, emotional and/or sexual abuse, including rejection Severe neglect and deprivation Misuse/abuse of alcohol/drugs Serious affective disorder eg depression Unresolved losses/childhood traumas Domestic violence Multiple placements

31 P.Fonagy and A. Bateman 2004 Abuse, neglect, trauma The caregiver fails to discover the child s intentionality Absence of a Representation of the infant s mental state Attachment figure in state of temporary dissociation Failed projection Internalisation Child Absent other internalised as part of the self Self representational structure The child, unable to find himself as an intentional being internalises a representation of the other into the self

32 Stress-response system Small to moderate amounts of stress experienced in predictable or patterned situations, help children develop brains that can regulate arousal, and minds that can develop coping strategies and resilience. However, if the stress is great, sudden, unpredictable, and threatening, it will be experienced as trauma with which young brains and minds cannot cope.

33 Developmental trauma In the event of a traumatic event, responses to sights, sounds, smells, touch and kinetic stimuli join with a rapid accelerating cascade of feelings from within to overwhelm the traumatised person. (Lieberman and van Horn 2008)

34 Early life trauma produces oversensitive stress-response systems. The brain loses its ability to regulate other functions including sleeping, eating, emotions, social relationships, and cognition.

35 Controlling Children Many abused and neglected children find mentalisation hard, particularly in interpersonal and intimate relationships because mentalising interactively is one of the most complex tasks. It is at these times that we are all vulnerable to hyperarousal and we need a buffer to protect us against overwhelming affect it is mentalisation that acts as a cushion. Bateman and Fonagy 2004

36 Feelings of helplessness and powerlessness increase the risk of trauma. Responses include hyperarousal, and under extreme trauma even dissociation. fight flight freeze The need to feel in control is high in situations of helplessness, powerlessness, vulnerability and trauma.

37 Controlling Children For maltreated children, hyperarousal throws mentalisation off-line the result is panic, impulsive behaviour, fight-flight response: makes children aggressive, impulsive, needy, frightened. Under extreme trauma, a freeze- dissociative response is more likely. Bateman and Fonagy 2004

38 Secure/optimal development Age Interventions eg adoption, relationship support, therapy Birth Sub-optimal/ Insecure/trauma etc

39 Secure/optimal development Age Sub-optimal/ Insecure/trauma etc

40 Bruce Perry: The ChildTrauma Academy, 5161 San Felipe, Suite 320 Houston, Texas 77056

41 Bottom-up, inside to outside Respond to developmental age and not chronological age Relationships as the most powerful of therapeutic experiences behavioural and cognitive development social support and relationships peer relationships social cognition, understanding, empathy mentalisation, play, attunement, affect regulation predictability, repetition, routines, structure safe and in control music, movement and dance sensory integration treatments rocking, touch, massage

42 A developmental base for interventions When intervening with children, it is important to assess their developmental age rather than their chronological age.

43 Secure/optimal development Intervention Age Intervention Intervention Sub-optimal/ Insecure/trauma etc

44 Secure/optimal development Age Attuned, psychologically minded teacher, drama/music therapy Emotionally intelligent best friend Intervention eg foster/ residential care. Sub-optimal/ Insecure/trauma etc

45 It is difficult for children to change without their environment also changing.

46 Patricia Crittenden 2008: Transitional attachment figure Practitioners need to be a bridge between the parent s dangerous reality and our safer one. Once the parent sees or feels that the practitioner understands, the worker can act as a transitional attachment figure in the parent s zone of proximal development. Treatment needs to involve psychological and behavioural reorganisation, as opposed to symptom reduction.

47 Adopt a mentalizing stance. Hold parent in mind + Hold the child in mind for the parent as a mentalizing being. Help the parent see that the child s feelings and behaviours are inextricably intertwined with theirs as a parent. Most importantly, I see the child s behaviour as meaningful. A. Slade (2008)

48 David Howe Child Abuse and Neglect attachment, development and intervention Palgrave/Macmillan 2005

49 David Howe The Emotionally Intelligent Social Worker Palgrave Macmillan 2008